A new device to stabilize templates for transperineal I-125 implants

A comprehensive review of prostate cancer brachytherapy: defining an optimal technique

PURPOSE

A comprehensive review of prostate cancer brachytherapy literature was performed to determine if an optimal method of implantation could be identified, and to compare and contrast techniques currently in use.

METHODS AND MATERIALS

A MEDLINE search was conducted to obtain all articles in the English language on prostate cancer brachytherapy from 1985 through 1998. Articles were reviewed and grouped to determine the primary technique of implantation, the method or philosophy of source placement and/or dose specification, the technique to evaluate implant quality, overall treatment results (based upon pretreatment prostate specific antigen, (PSA), and biochemical control) and clinical, pathological or biochemical outcome based upon implant quality.

RESULTS

A total of 178 articles were identified in the MEDLINE database. Of these, 53 studies discussed evaluable techniques of implantation and were used for this analysis. Of these studies, 52% used preoperative ultrasound to determine the target volume to be implanted, 16% used preoperative computerized tomography (CT) scans, and 18% placed seeds with an open surgical technique. An additional 11% of studies placed seeds or needles under ultrasound guidance using interactive real-time dosimetry. The number and distribution of radioactive sources to be implanted or the method used to prescribe dose was determined using nomograms in 27% of studies, a least squares optimization technique in 11%, or not stated in 35%. In the remaining 26%, sources were described as either uniformly, differentially, or peripherally placed in the gland. To evaluate implant quality, 28% of studies calculated some type of dose-volume histogram, 21% calculated the matched peripheral dose, 19% the minimum peripheral dose, 14% used some type of CT-based qualitative review and, in 18% of studies, no implant quality evaluation was mentioned. Six studies correlated outcome with implant dose. One study showed an association of implant dose with the achievement of a PSA nadir < or = 0.5. Two studies showed an improvement in biochemical control with a D90 (dose to 90% of the prostate volume) of 120 to 140 Gy or higher, and 2 additional studies found an association of clinical outcome with implant dose. One study correlated implant quality with biopsy results. Of the articles, 33 discussed evaluable treatment results, but only 16 reported findings based upon pretreatment PSA and biochemical control. Three- to 5-year biochemical control rates ranged from 48% to 100% for pretreatment PSAs < or = 4, 55% to 90% for PSAs between 4 and 10, 30% to 89% for PSAs > 10, < or = 20 and < 10% to 100% for PSAs > 20. Due to substantial differences in patient selection criteria (e.g., median Gleason score, clinical stage, pretreatment PSA), number of patients treated, median follow-up, definitions of biochemical control, and time points for analysis, no single technique consistently produced superior results.

CONCLUSIONS

Our comprehensive review of prostate cancer brachytherapy literature failed to identify an optimal treatment approach when studies were analyzed for treatment outcome based upon pretreatment PSA and biochemical control. Although several well-designed studies showed an improvement in outcome with total dose or implant quality, the numerous techniques for implantation and the varied and inconsistent methods to specify dose or evaluate implant quality suggest that standardized protocols should be developed to objectively evaluate this treatment approach. These protocols have recently been suggested and, when implemented, should significantly improve the reporting of treatment data and, ultimately, the efficacy of prostate brachytherapy.

Interstitial implantation techniques in prostate cancer

Brachytherapy is a radiotherapeutic technique that allows the physician to implant radioactive isotopes into a body cavity or directly into tissue. Different radioisotopes have unique characteristics that the brachytherapist may utilize for a particular situation. The use of brachytherapy is part of standard radiation oncology practice in gynecological and head and neck cancer management. The prostate is approachable for interstitial implantation due to its close proximity to the perineum. Over 20 years ago, primitive methods of brachytherapy were utilized in the treatment of prostate cancer. However, poor results due to inconsistency in achieving adequate coverage of the entire prostate and poor patient selection caused this treatment modality to fall out of favor. Technological advances over the last decade have restored attention to brachytherapy for prostate cancer. Particularly important has been the development of transrectal ultrasound, new radioisotopes such as palladium-103, computer tomography, computerized dosimetry systems, and earlier diagnosis. Modern interstitial implantation utilizing transperineal template and transrectal ultrasound guidance has resulted in improved consistency in radiation dose delivery to the entire prostate. Early results are encouraging in terms of the relatively low morbidity of the procedure, improved local control rates, and biochemical progression free survival. This has resulted in an outpatient treatment that has high patient acceptance.

A modified technique allowing interactive ultrasound-guided three-dimensional transperineal prostate implantation

PURPOSE

Ultrasound-guided transperineal prostate implantation is a new technique for performing permanent isotope implants of the prostate. The details of the technique are presented to demonstrate its ability to place radioactive seeds three-dimensionally within the prostate gland to achieve uniform dose distribution without the need for complicated preplanning.

METHODS AND MATERIALS

An accurate measurement of the prostate volume is made using biplanar transrectal ultrasound. The total activity to be implanted is derived from a look-up table based on prostate volume. The basic plan is to implant 60-70% of the total activity in the periphery of the gland and the remaining activity in the interior of the gland. The ultrasound transducer provides visualization of the prostate through transverse, longitudinal and oblique cuts and allows for accurate placement of implant needles, approximately 1 cm apart. In addition, these needles can be moved through the prostate under constant visualization, thus allowing for precise seed placement.

RESULTS

The setup of the transrectal ultrasound device as well as prostate volume measurements are performed in 10 to 15 min. The actual placement of the needles and seed implantation takes 1 to 1.5 h to perform. Postimplantation dosimetric evaluation is performed using orthogonal x-ray films and 3 mm thick CT slices taken at 3 mm intervals. This evaluation has confirmed accurate seed placement within the prostate gland.

CONCLUSION

Interactive ultrasound guided transperineal prostate implantation is a fast and accurate method of performing permanent radioactive isotope prostate implants.

CT-based optimized planning for transperineal prostate implant with customized template

A computerized planning procedure has been developed for CT-guided transperineal prostate implants. The segment for custom planning of perineal needle orientations allows placement of I-125 seeds in the entire prostate gland while avoiding the pubic bones. Least-squares optimization (LSO) is used to obtain the seed-loading pattern along the needles. The optimized seed distribution produces a better fit between treatment and target volumes than that obtained from our previous manual technique. Also, the present semi-automatic technique reduces planning time by about a factor of 10 compared to that of the manual approach.